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MALTREATMENT INVESTIGATION MEMORANDUM Minnesota Statutes, section 626.557, subdivision 1 states, “The legislature declares that the public policy of this state is to protect adults who, because of physical or mental disability or dependency on institutional services, are particularly vulnerable to maltreatment.”
License Number and Program Type: 1098861-AFC (Adult Foster Care) 1069963-HCBS (Home and Community-Based Services) Investigator(s): Thomas Nixon 651-431-2155 Suspected Maltreatment Reported: It was reported that a supervisory staff person (SP) and a vulnerable adult, got into an altercation resulting in the SP slapping the VA, grabbed the VA’s hair, and pulling the VA to the ground. Date of Incident(s): July 31, 2024 Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (b), and Minnesota Statutes, section 626.5572, subdivision 15, and subdivision2, paragraph (b), clause (1): Conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult. Summary of Findings: Pertinent information was obtained during a site visit conducted on August 22, 2024; from documentation at the facility and law enforcement records; and through six interviews conducted with the SP, a supervisory staff person (P3), two supervisory staff persons (P1 and P2) for the HCBS license, and the VA’s case manager (CM). The SP’s and P3’s two family members (FM1 – FM2) who were children and the VA’s child (C) present during the incident, but due to their ages they were not interviewed. Lutheran Social Service (LSS) of Minnesota was licensed to provide Home and Community-Based Services (HCBS), and Michael Tate Goeden & Kimberly Marie Dysthe Goeden Adult Foster Care (AFC) was a licensed adult foster care facility. LSS and the AFC had a contracted relationship, meaning the SP and P3 were each a direct support staff person under the HCBS license held by LSS. P1 and P2 provided program coordination and management of the HCBS license held by LSS. The SP and P3 were also AFC staff persons. Throughout this report, “facility” refers to the adult foster care facility and the services provided therein. The VA enjoyed spending time with the C, shopping, keeping busy, and spending time with a community person (CP). The VA’s diagnoses included reactive attachment disorder, attention deficient hyperactive disorder combined, major depressive disorder, and intermittent explosive disorder. The VA had a history of verbal and physical aggression, and threatening behaviors towards. The VA’s Psychotropic Medication Monitoring and Use form stated “[The VA] states that it will only escalate [him/her] anger if you tell [him/her] to calm down. [The VA] states [s/he] will go to [his/her] room if [s/he] is upset and likes to listen to music to try to nap. [The VA] will talk about the situation once [s/he] has calmed [him/herself].” The VA’s Coordinated Service and Support Plan (CSSP) Addendum stated, “[SP1 and SP2] will assist [the VA] with de-escalation if they witness [him/her] having trouble controlling [his/her] anger. If [SP1 and SP2] are unable to deescalate the situation, [they] will make sure themselves and [the C] are safe and call 911 or the mental health crisis line. If [the CP] is in the home at the time of conflict [s/he] will take [the C] out of the area of conflict. If [the CP] is not in the home at the time of conflict then [SP1 and SP2] will ensure the safety of [the C].” The VA’s Individual Abuse Prevention Plan stated under risk of physical abuse, “[SP1 and SP2] will assist [the VA] when [s/he] is feeling emotional and will notify [his/her] mental health care team as needed for assistance.” The VA’s Self-Management Assessment stated that “once [the VA] has become upset, it is hard to talk rationally with [him/her] and it is best to just let [him/her] yell about what [s/he] is upset about and give [him/her] space to calm [him/herself]. [The VA] may just leave [the C] alone when [s/he] is this upset.” The VA provided the following information: · The VA and the C lived at the facility for five years and the VA “like[d]” it, despite “differences, mostly about parenting” styles for the C. If the VA “struggle[ed]” with the C for six minutes, the SP and P3 could “step in” to help by saying, “I see you are frustrated,” and then offer for the VA to “walk away and come back to the situation” while they handled the C. · At times, the SP and P3 “invalidate[d]” the VA’s parenting methods and sometimes the VA did not think s/he needed help with the C, but the SP and P3 thought s/he did and stepped in to help. This “irritated” the VA and things went “downhill from there.” Sometimes, the SP told the VA that s/he “need[ed] to parent better.” · When the VA told the C, “No,” the C went to the SP and P3 instead of listening to the VA. When the VA was “upset or mad,” the SP and P3 removed the C away from the VA. There were times when the VA thought it was “a good things in the moment,” but s/he disagreed because s/he was already “mad.” Sometimes, the VA and the SP were both “mad” and then they “tend[ed] to argue” and “feed off each other.” In those situations, the VA and the SP tried to “steer clear” of each other. When the VA was upset s/he wanted to be left alone in his/her room until calm. · On an unknown date, the VA, the SP, the C, FM1, and FM2 were downstairs due to a storm. After the storm passed, the VA went upstairs to his/her room to “decompress,” but s/he did not tell the SP. The SP had the C, FM1, and FM2 outside. The VA thought both s/he and the SP were “stressed out” from the storm. · The SP came into the facility and asked what the VA was doing. The VA told the SP s/he was sleeping. The SP sounded “a little irritated, frustrated, stressed,” and told the VA to come help with the C since the SP needed to put away the groceries and deal with FM1 and FM2. The VA came out of his/her bedroom, got the C, and they returned the VA’s bedroom. The C began to “kick, holler, [and] scream” so the VA put the C in his/her own room for a “timeout.” · When the C calmed, the VA got the C out of his/her bedroom and they went and joined the others in a living room area. The VA and the SP sat in chairs while FM1, FM2, and the C played on the floor. The SP and the VA started to “nitpick each other.” The VA told the C one thing, and the SP told the VA that the C had not do anything wrong and had not needed a timeout. · The VA and the SP were “both already agitated” while the C played with a car the SP got him/her. The VA was on the phone with a family member when the C threw a toy at the VA. The VA then warned the C that if s/he threw it again, the toy would be thrown away. The C threw the toy again at the VA. The VA got off the call and took the toy from the C. · The VA then went outside through the garage, to the garbage, and threw the toy away. The SP followed the VA outside and told the VA to “calm down.” As the VA came around the corner of the garage towards the facility to return inside, the VA moving “fast” and turned into the SP. The SP “put [his/her] hands up” and “extended them” like a “brace.” The SP’s “slight… push” was “not on purpose,” but the SP “clearly… thought I was going to attack [him/her].” The VA said that when s/he was upset, s/he “wanted people out of [his/her] face” and not touch the VA. If the VA was touched when s/he was upset, s/he went into “flight or fight mode.” · When the SP put up his/her hands, the VA thought the SP “pushed” him/her so then they “both started scuffling and fighting.” The VA “grabbed” the SP’s hair with his/her right hand and told the SP, “Don’t touch me, don’t push me.” The SP was “trying to calm me down,” but the VA was “in fight mode.” · The VA said that at one point, when they were both standing, the SP used his/her left hand to grab the VA’s hair. The SP told the VA, “Calm down. Let go. It is going to be okay.” Then the SP “probably leaned back” and the VA “flipped over” on to the ground. The VA said it was “like toddlers rolling around.” The VA and the SP then stood while they held the other’s hair. The VA said that at one point s/he “stomped” on the SP’s glasses that had fallen. The VA said that at some point after, the SP told him/her that the VA had his/her knee on some part of the SP, but the VA did not remember having done so. The VA could not remember whether the SP slapped the VA during the incident, but thought the SP “might” have and “probably did.” The VA did not remember some details of the incident because s/he “blacked out.” · During the incident, FM1, FM2, and the C came outside, saw what was happening, and the SP said they “need[ed] to stop” and “let go on the count of three.” The SP counted to three and they both let go. Everyone returned inside the facility, where the SP and the VA each called 9-1-1. Law enforcement came to the facility, talked with the VA and the SP and told them that either they could both go to jail for domestic assault or one of them had to leave the facility for the night. The VA and the C then left the facility, went to a hotel for the night, and returned the next day. · The VA said s/he sustained marks from the incident and thought they were from the “cement… ground or wrestling.” The VA said s/he did not think that that SP “grabbed or scratched” the VA, but also said injury on his/her head was “probably from [the SP] grabbing [the VA’s] hair.” · At some point, the SP texted the VA saying that s/he was “sorry.” When the VA returned to the facility, s/he did not talk to the SP for the next day or two. The VA were both “surprise[d]” about what had happened. The VA thought the incident lasted approximately ten minutes. Photos of injuries to the VA showed a red mark behind the VA’s right ear just above the hairline that appeared to be blood, scrapes and bleeding on the right shin, an abrasion to the VA’s right hand middle finger knuckle, and a scrape to the VA’s right foot outer ankle. At the time of the site visit the VA’s marks were scabbed over. Photos of injuries to the SP showed scrapes to the top of the SP’s right hand, a scrape to the top of the SP’s left wrist, scrapes to the SP’s right big toe, scrapes to the top of the SP’s left foot, and scrapes and dirt to the SP’s left elbow. The SP provided the following information: · The VA previously demonstrated physically aggression towards the SP and P3 which included pushing, punching, and kicking, and property destruction. In the past, P3 used a manual restraint on the VA. The SP and P3 tried to “avoid” calling 9-1-1 and would contact P1 and P2 about situations, but at times 9-1-1 was “unavoidable.” The SP said that when the VA demonstrated physical aggression, the VA “blacked out and doesn’t remember.” · The C was the VA’s responsibility and the SP “love[d] and care[d]” for the C “very much” and referred to him/her as their family member. The SP said it was “hard to watch” the VA “put [him/herself] first” before the C. The SP and P3 “just handled situations like we’re a family.” · On July 31, 2024, around noon, the SP, the VA, the C, FM1, and FM2 were home and the weather was “really bad.” When the tornado sirens sounded, the group went downstairs to the basement for about 45 minutes until the storm passed. Afterwards, the SP took the C, FM1, and FM2 outside to play. At one point, the SP looked for the VA but did not see him/her. The SP went inside and called out for the VA. The VA then responded that s/he was sleeping. The SP told the VA to come care for the C, and that if s/he did not want to watch the C, the VA needed to ask for help. The SP returned outside with FM1, FM2, and the C. The VA came to the outside door and called for the C to come inside. When the C said s/he did not want to go inside, the VA came out to the C, picked him/her up, and carried the C inside. · The SP stayed with FM1 and FM2 outside “for a little bit longer” and then they went inside. At that time, the SP heard the C in his/her room, “kicking and screaming and freaking out.” The SP saw the VA sitting in front of the C’s door to ensure the C stayed in the bedroom. The VA told the SP that the C did not listen to him/her and the SP told the VA that the C did not do anything wrong. The SP left the area and eventually the VA and the C joined the SP, FM1, and FM2 in the living room. · The SP and the VA were sitting in chairs while FM1, FM2, and the C played with remote control cars in the middle of the floor. The VA was on the phone with his/her family member and got upset with the C for being too loud. The VA told the C s/he was going to “throw that toy away.” The SP told the VA s/he was not going throw the toy away because the SP had “just bought it.” · The VA then “grab[bed] the toy from [the C]” and left out the door into the garage, and turned the corner out of the garage towards the garbage. The SP followed the VA into and through the garage. When the SP got to the corner s/he “bump[ed]” into the VA as the VA came back around the corner into the garage. The VA “kind of threw [his/her] shoulder” into the SP’s shoulder. · The SP put his/her hand up and “gently grabbed [the VA’s] arm” and told him/her, “This needs to stop. This is enough.” The SP “instinctually grabbed” the VA’s arm, but “didn’t squeeze the arm or anything.” The SP was aware that touching the VA typically “upset” the VA, but “I wasn’t thinking about that in the moment.” The SP hoped to resolve the situation before the VA went back inside and was in front of the C, FM1, and FM2. The SP denied pushing the VA or extending his/her arms towards the VA. · The VA said, “Don’t touch me, you fucking bitch” and then “grabbed” the SP’s hair and began pulled it. The SP told the VA to “let go.” The SP then bent over to try to maintain his/her balance and get away from the VA. While bent over, the SP tried to “grab onto the VA” and then tried to “push” the VA away. The SP “pulled away” and in the process, the SP’s hand “caught” the VA’s hair accessory which was pulled off. This “sent [the VA] over the edge” and the VA punched the SP in the face and head. The SP’s glasses fell to the ground and the VA “stomped and broke them.” During this time, FM1, FM2, and the C came outside. · The SP “[tried] to push [the VA] away” but the VA would not let go of the SP’s hair. The SP told the VA, “Let go. Stop.” The SP then “crouched” down to his/her knees in an attempt to protect his/her face from being punched. The VA “pushed” the SP over on to his/her back and got on top of the SP and tried to punch the SP in the face. The C was yelling at the VA to stop and throwing things at the VA. · The VA continued holding onto the SP’s hair and calling the SP “a bitch.” The VA moved him/herself higher up the SP’s body so that the VA’s knees were by the SP’s shoulders. The VA then put his/her knee on the SP’s throat restricting the SP’s breathing. The SP was unable to speak to the VA due to the pressure on his/her throat. The SP tried “super hard” to “wiggle free” from the VA. · At some point, the VA let go of the SP’s hair and the SP was able to get out from under the VA. The SP stood and the VA again grabbed the SP’s hair. The SP used his/her left hand and grabbed the VA’s hair on the right side of the VA’s head. The SP said, “It was the only thing I could do.” The SP then told the VA they were going to “let go” of each other’s hair. The VA agreed and after the SP counted one, two, three, they each let go. · The SP took FM1 and FM2 into the house where the SP called 9-1-1. The SP requested law enforcement “immediately” and they arrived within 15 minutes or less. While the SP was on the phone with 9-1-1. the VA and the C stayed outside. · Law enforcement officers talked to the SP and the VA arrived interviews were completed, and photos were taken of injuries. Law enforcement did not talk with the C, FM1, or FM2. The SP thought the injuries to VA were from when they were on the ground together due to the “leaves, sticks, [and] mulch” outside. Neither the VA nor the SP required medical care. A law enforcement officer told the SP s/he planned to ask the VA to “leave the [facility] for the evening for everything to settle down.” · The VA and the C went to a hotel for the night and then the next few nights, the SP was out of town. The VA later told the SP that s/he had been “really anxious” while in the basement because it was a small room and FM1, FM2, and the C were “loud and running around.” The VA later told the SP that the SP “slapped” the VA, but the SP did not recall doing so. The SP thought that the physical altercation lasted about 10 minutes. · The SP completed training on the emergency use of manual restraints. The SP said that training for when a person grabs a staff person’s hair, “I’m sure it was not grab onto [the VA’s] hair.” The SP did not recall what the training instructed him/her to do if the VA grabbed his/her hair. P1, P2, P3, and the CM provided the following information: · The SP and P3 were to support the VA’s mental health, medication compliance, and assist with parenting the C. The VA saw the SP and P3 as “family” and “love[d] them.” · The VA had history of verbal and physical aggression and property destruction usually resulting from disagreements on parenting the C. P1 said that when there were issues between the SP and the VA, the SP removed him/herself and the VA and P3 talked. If the SP and P3 were not able to support the VA during an incident 9-1-1 was called, which happened “every few months.” · P3 said s/he and the VA got along “well.” The VA daily brought his/her “struggles” to P3 to discuss. While P3 attempted to come up with a plan with the VA, the VA’s reaction was usually to “resist” the advice at first. The VA later reflected on the advice and usually then agreed. When the VA was “combative” and “aggressive,” the SP and P3 were to be “protective and remove” the C from the incident and then try to “de-escalate” the VA. If there was “imminent danger” to the VA or others the SP and P3 were to physically intervene and if there was “extreme aggression” they were to call 9-1-1. · P3 said it was a “daily” conversation with the VA about his/her role and responsibilities with the C. The VA was to ask the SP and P3 to help with the C when s/he needed “a break.” The C’s “high energy” at times impacted the VA’s “anxiety.” If the VA expected the help without asking for it, the VA got “frustrated” and might be “short” with the C, “stomp[ed] on the floor,” and “[threw] blankets.” When this occurred, P3 “hover[ed]” in the area to “make sure everything’s okay.” The VA asked the SP and P3 that when s/he was “40% elevated” to help him/her with the C. The SP and P3 “care[d]” for the C “75% of the time” typically after the VA got home from his/her job and was “too tired.” The SP and P3 assisted the C with his/her routine in the evenings when the VA was not present. · The CM thought “lines [got] crossed” at the facility regarding the C. The CM told the SP and P3 that the VA was the parent and was the decision maker for the C aside from any emergency. When there were issues at the facility, the VA talked about moving out, but once things “cool down,” the VA and SP “hug about it” and the VA changed his/her mind. · P2 was a support person for the SP and P3 for training and documentation and advocated on behalf of the VA. · On July 31, 2024, at 4:40 p.m., the VA texted P2 that s/he was “frustrated” and “needed to talk.” At 5:10 p.m. the VA again texted P2 that the SP “put [his/her] hands on me” and the VA “wanted out.” The VA sent four photos of injuries. Because P2 was not working that day reached out to his/her supervisor and was told not to contact the SP and P3 at this time. · Around 5:10 p.m., the VA called P1 and was “pretty escalated” and wanted “out” of the facility. The VA said s/he was “fucking done” because the SP “attacked” him/her. The VA told P1 about throwing the C’s toy away and that then the SP “grab[bed]” the VA and started “throwing fists” at the VA. The VA had the “scratches to prove it” and needed to “protect” him/herself from the SP. The VA called 9-1-1- and was concerned that no one believed him/her that the SP went after the VA “first.” The LE told the VA to leave the facility. The VA arranged a hotel room for him/herself and the C. · Two to three hours later, P1 talked with the SP on the phone. The SP was “emotionally distraught” and “crying.” The SP stated that the C hit the VA with a toy car and the VA warned the C that if it happened again the car would be thrown away. The SP told the VA not to throw it away because the SP had just bought it for the C and told the VA to take it away instead. The VA called the SP a “bitch” and said s/he “can do what [s/he] wants.” The SP told P1 that the VA “came at” the SP first, “pushed” the SP, “grabbed” the SP’s hair, and hit the SP “multiple times.” The VA “drug [the SP] to the ground” and they “rolled around for a bit.” As a result, they both had “marks” on them. The SP thought the marks on the VA were from when they rolled on the ground. · On August 1, 2024, the CM called the VA about the incident. The VA told the CM about why s/he threw the toy car away and that the SP came outside after the VA and said s/he “can’t throw the car away” and they argued. The SP “started swinging” at the VA and “slapped” the VA’s face. The SP “grabbed” the VA’s hair and “pulled” him/her to the ground. The VA said s/he “touched” the SP, but that the SP “touched [the VA] first.” · After the incident, P3 talked to the VA who provided information that was consistent with the information the VA provided during his/her interview. The VA also told P3 that after the toy was thrown away as s/he came around the corner, s/he “chest bumped” the SP. The SP’s glasses fell off and were stomped by the VA prior to the VA striking the SP. · On August 1, 2024, the VA and the C returned to the facility. According to P3 things were “good” and “normal” when they returned. It was “typical” for the VA to see “good” after an incident occurred. The SP returned two days after the incident and got along “normally” with the VA. · P1 said that while the VA might “blow things out of proportion” when in “crisis,” once the VA calmed s/he “accurately” told others what happened. While the VA “always” took “ownership” when s/he was physically aggressive, this was the first time the VA said someone else physically aggressed towards him/her first. P2 said that while, the VA did “not make things up,” his/her “perception might be different than others,” and did not want to “get others in trouble.” The CM said the VA’s recollection could be different when s/he was “heated or stressed.” The CM did not know the VA to “lie” and told things how s/he “perceives it at the time.” P3 said the VA had “zero” awareness when s/he got “overwhelmed.” · P1 said the facility was a “hands off services.” Staff persons were not trained on restraints. Staff persons were taught de-escalation techniques, “hair pull releases that are allowed,” and to get away and call 9-1-1. P1 said that from what the SP described to P1, the training on hair pull techniques was not followed. P2 did not think there was training on de-escalation, blocking, and physical interventions. P3 said that s/he and the SP went through “six hours” of physical intervention training which reviewed various scenarios, de-escalation tactics, and types of restraints. There was an annual computer module refresher. P3 said s/he and the SP were not trained on how to respond to choking attempts during the physical interventions training. Law enforcement officers responded to the 9-1-1 calls, but no charges were filed. Facility documentation showed the SP and P3 received training on the Positive Behavior Interventions and Supports and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: Information was consistent that on July 31, 2024, in the afternoon, there was a physical altercation between the VA and the SP when the VA took the C’s toy away and went outside to throw it away. The VA went outside through the garage towards the garbage can followed by the SP. The VA threw the toy away and turned to come back into the garage and when s/he turned the corner the VA and the SP collided in some manner which started the physical altercation. The VA provided inconsistent information regarding who started the altercation. The VA told P1 and the CM that the SP started the altercation by “swinging” at the VA and “attacking” the VA. However, the VA told this investigator that s/he was upset that the SP touched him/her and that s/he grabbed the SP’s hair. The VA also stated that s/he did not recall details of the incident because s/he “blacked out.” The SP said that when they collided, s/he gently grabbed the VA’s arms, which upset the VA. The VA then grabbed the SP’s hair and as the VA held the SP’s hair, the VA’s physical aggression towards the SP continued with the VA punching the SP in the face and head, them falling onto the ground, and eventually with the VA straddling the SP and putting his/her knees on the SP’s throat, restricting the SP’s breathing. Although it was possible that during the incident the SP hit the VA and pulled the VA’s hair, given that the initial contact between the VA and the SP was incidental as they each turned the corner into one another, that the VA told this investigator that s/he initially pulled the SP hair, that the VA had a hold of the SP’s hair for most of the incident, and at one point had the SP on the ground restricting the SP’s breathing, there was no a preponderance of the evidence whether the SP all of the SP’s actions were therapeutic conduct or whether the SP engaged in conduct which produced or could reasonably be expected to produce physical pain or injury or emotional distress. It was not determined whether physical abuse occurred (conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult; and/or the use of repeated or malicious oral, written or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening). Action Taken by Facility: The AFC and LSS each completed an internal review. Each determined that while the policies and procedures were adequate, they were not followed. Each stated there were similar events in the past where law enforcement was called to the facility. While the AFC stated there was no need for additional training, the SP retook the Positive Support Training and LSS planned to discuss the training with the SP about to support the VA. LSS determined that the following additional actions were required: · Retraining on the VA’s plans · Retraining on Maltreatment of Vulnerable Adults · Retraining on Emergency Use of Manual Restraints Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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